Intracranial Hemorrhage: Evaluation

by Roy Strowd, MD

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    00:01 First, let's take a look at hypertensive hemorrhages.

    00:05 This is a classic example of a hypertensive hemorrhage.

    00:08 There's a deep area of hyperdense blood in the subcortical regions and we see these in the thalamus, internal capsule of pons, and even in the cerebellum. Hypertensive hemorrhages are subcortical. They occur in small vessel territories like the basal ganglia, internal capsule thalamus and cerebellum. They present with focal neurologic deficits in a patient who presents with new hypertension or refractory hypertension from longstanding disease. We manage this typically with monitoring over time to ensure there's not propagation and if so some patients rarely may need surgery but the vast majority are managed conservatively. And the long-term treatment that is necessary is management of the patient's hypertension. Now let's talk about the second category or hemorrhagic transformation of an ischemic infarct. This is the second cause of an intraparenchymal hemorrhage. Here, we're looking at a number of the images of a patient who presented with a new focal deficit. This patient had a right hemiplegia and we were concerned about a left hemispheric problem. On the far right, you're looking at perfusion image and that green is an area of reduced perfusion. That's an area at risk for stroke. There is reduced perfusion in the left MCA territory. The patient had a non-contrast head CT which you see in the middle which shows some early blurring of the gray white junction in the subcortical structures of the insular cortex of the left MCA territory and then on the CTA at the far right we see a cutoff sign. You can see a really healthy nice looking right MCA with full opacification and blood and then a cutoff at the left MCA from an acute thrombus in that territory. So this is the typical imaging findings of a patient presenting with a left MCA syndrome. This patient underwent intervention and a day after intervention instead of seeing an area of restricted diffusion on the diffusion weighted image, we saw this kind of black and white heterogenous area. That was followed by a head CT around that same time for neurologic deterioration and what we're seeing was hyperdensity in that area of recent stroke consistent with new bleeding or hemorrhagic transformation of this patient's ischemic infarct. And then ultimately on the susceptibility weighted image which is an MRI sequence, we see this area of dark signal, reduced signal on the susceptibility weighted image which is consistent with a hemorrhagic infarct. Typically, we see hemorrhagic transformation within that three to five days or sometimes out to seven days after an ischemic infarct. Hemorrhagic transformation is more common in large strokes. This patient presented with a large paroxysmal MCA occlusion, a large area of tissue that ultimately was involved. And those patients are at higher risk of hemorrhage, particularly after acute intervention or other reperfusion interventions.

    About the Lecture

    The lecture Intracranial Hemorrhage: Evaluation by Roy Strowd, MD is from the course Stroke and Intracranial Hemorrhage.

    Included Quiz Questions

    1. Basal ganglia, internal capsule, thalamus, cerebellum
    2. Broca's area, Wernicke's area, occipital cortex, thalamus
    3. Frontal lobe, parietal lobe, hippocampus, mammillary bodies
    4. Corpus callosum, Temporal lobe, brainstem, pons
    5. Cerebellum, brainstem, thalamus, pons
    1. Hemorrhagic transformation; non-contrast CT
    2. Hemorrhagic transformation; MRI
    3. Subdural extension; non-contrast CT
    4. Undiagnosed vascular lesion; catheter angiogram
    5. Underlying intracranial tumor; MRI

    Author of lecture Intracranial Hemorrhage: Evaluation

     Roy Strowd, MD

    Roy Strowd, MD

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